HospitalInspections.org

Based on interview and review of internal hospital documents, it was determined that the hospital failed to establish a process that ensured that all patient grievances were reviewed and resolved. The hospital's failure to do so resulted in 1 patient who had reported being raped in the hospital's Emergency Department (ED) not having her/his grievance investigated, and potentially placed other patients at risk for not having their grievances investigated and resolved.

Findings include:

On 4/1/2013, the DQARM was asked to provide a list of all grievances received in the month of January, 2012 [the period of the alleged rape in the ED] and a list of all grievances received in February and March, 2013. The lists were reviewed, and the name of the alleged victim, Patient #1, was not found in the list of patient grievances for the month of January.

On 4/1/2013, the Director of Quality Assurance/Risk Management (DQARM) was asked about the missing name, and asked if maybe the name was on another list. The DQARM stated that the patient's allegations had not been entered into the Grievance Process, and that was why her/his name could not be found.

The hospital's policy and procedure "Management of Patient Grievances" was reviewed and found to contain the following directives:

"Policy Statement:
As part of the Patient's Rights, Highline Medical Center has established a process for hearing, investigating and communicating with patients who have grievances about their care.

Purpose:
To describe the process for responding to patient grievances, including time frames, responsibilities, expectations related to communication with patients, resolution of grievances, and dispute resolution...

Procedure:
"...
4. Upon receipt of the grievance, the Quality Services Department will do the following:...
c. Conduct an investigation...

9. Once the investigation is completed, the findings and outcome will be communicated to the patient. The patient will be informed of:
a. The steps taken on their behalf to investigate the grievance
b. The results of the grievance process
c. Date of completion of the grievance
d. Name of the contact person should the patient have additional questions or concerns or is not satisfied with the outcome.

Grievance Process monitoring and data collection:
1. At the time a grievance is received, the person in contact with the patient will enter the information including patient name, contact information and a brief summary of the concern into Quantros [incident reporting data base] in the "Feedback" section
2. When indicated, Quality Services will also escalate the grievance to Risk Management and Patient Safety...
5. Quality Services will maintain copies of all communication with the patient."

On 4/1/2013, the DQARM stated that the allegations brought forth by Patient #1 had not been processed as a grievance. When the DQARM was asked why not, s/he replied that, because local law enforcement had been called and responded to the ED immediately, s/he had considered the issue resolved in the moment, and as such was a "complaint" and not a grievance".

The Department of Health Investigator informed the DQARM on 4/1/2013 of the Federal definition of a grievance, per CFR 482.13(a)(2) which states, in the interpretive guidelines:

"...All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are considered a grievance for the purposes of these requirements"

The DQARM acknowledged that the hospital's failure to process the allegation of Patient #1 as a grievance, resulted in the lack of a thorough investigation as well as the lack of communication with the patient.

Based on interview, review of media reports, review of medical records and review of internal hospital documents, it was determined that the hospital failed to assure that 2 former patients of the hospital were free from abuse or harassment. The hospital's failure to do so resulted in one patient, Patient #1, reportedly being raped while in the hospital's Emergency Department (ED) without a report to the State Department of Health. A second patient, Patient #2, sustained injuries while in the hospital's Geropsychiatric Unit, which were not reported to the State Department of Health. The hospital's failure placed all patients in the hospital at risk for unreported and uninvestigated patient abuse and neglect.

Findings include:


Patient #1
Patient #1 was a patient in the hospital's ED on January 24, 2012. A review of the patient's medical record revealed that during the time the patient was receiving care in the ED, s/he reported to the physician providing care that s/he had been raped by an ED technician. Physician's notes of that date state:

"...pt. alleged that male tech while cleaning wounds, was cleaning back (no injury here) but stated that though was "'blood back there" so allowed cleaning. Then stated that was bumped in back by techs penis. [S/he] alleged that he came around to other side of bed and exposed himself to [her/him] stating 'look how big I am'...

[S/he] described that he cleansed/wiped [her/his backside after asking her to lie on [her/his] L side, then had [her/ him] lie supine cleansing [her/ his] anterior are (Pt. rolled from L side to supine indicating movements as well as pulling down underwear. Mentrual [sic] pad noted in place.) [S/he] also Pt stated [sic] that this was the 1st chance to speak to staff after alleged assault...pt stated that lubricant was placed about [her/his] rectal area and there was penetration rectally.
Charge nurse notified, risk management notified. Pt. offered/accepted contact to police and forensic exam."

The physician's notes in the record also documented that the police had been called and were en route, social services had been notified and hospital security was at the patients's bedside. The record also documented that the patient was discharged to another hospital for a forensic sexual assault examination.

On 4/1/2013, this Department investigator called the patient for an interview. The patient initially answered the phone, then asked the investigator to call back later. Two additional calls to the patient on the same date were unanswered.

On 4/2/2013, the ED physician who had cared for the patient was interviewed. The physician stated that her/his immediate response had been to direct the ED technician to not return to the room because the patient had accused the technician of sexually assaulting the patient. The physician stated that s/he also immediately informed the charge nurse and the local police were called. The physician stated that during the same period of time, s/he also informed the hospital's Director of Quality Assurance/Risk Manager (DQARM) of the events.

The DQARM was interviewed throughout the 3-day investigation, on 4/1, 4/2 and 4/4/2013, and asked to describe the hospital's investigation into the alleged events, including how, when, and to whom in the Department of Health the hospital had reported the allegation and the ED technician. The DQARM confirmed on 4/1, 4/2 and 4/4/2013, that neither the allegations made by the patient or the technician with State-issued credentials, had been reported to the Department.

On 4/1/2013, the DQARM confirmed that the ED technician had not been reported to the State Department of Health, an adverse event had not been reported to the Department and a root cause analysis of the events had not been conducted. The DQARM stated that the hospital did not report the alleged rape as an adverse event because the rape was not "confirmed". S/he also stated that the hospital RM department believed that it would be informed by the King County Sheriff's detective when, and if, the Sheriff's Department confirmed the rape. The DQARM confirmed that the hospital had not initiated contact with the Detective.

When asked if the ED technician had been required to leave the hospital immediately, the DQARM stated s/he did not know. The DQARM stated that the ED technician had been placed on administrative leave, but had subsequently signed a voluntary termination agreement on 2/23/2012. When asked why the ED technician had not been terminated, the QARM stated that it was "hard to terminate in a union environment."

The DQARM acknowledged that the ED technician held a Nursing Assistant Registered certification and a Health Care Assistant certification, both with the State of Washington Department of Health. Review of the ED technician's personnel file confirmed both. The DQARM also acknowledged that by not reporting the allegations to the Department, the ED technician had not been investigated by the Department and had been free to seek employment elsewhere, due to the 2 unencumbered certificates.


On 4/2/2013, the King County Sheriff's detective was interviewed and stated that s/he had received the results of the DNA (evidence testing) results in June of 2012. The detective was asked if s/he had shared that information with the hospital and stated that s/he had not. The detective stated that s/he had not gotten any questions from the hospital and at that time.

Patient #2
Review of internal patient incident reports revealed that on 1/21/2013, Patient #2, a patient on the hospital's Geropsychiatric Unit, had been found in her/his bathroom with her/his pants and incontinent briefs down around her/his knees. The aide (Certified Nursing Assistant) was observed standing by the first bed in the room, with her/his hands raised. The report stated that the aides hands were "covered in blood", and the aide reportedly stated "I had to grab [the patient]". The internal written report was 6 pages long and documented that the patient had bruising from elbows to wrists on both arms, with the skin peeled off and twisted on both arms and both arms were bleeding.

On 4/4/2013, the DQARM was asked if the incident involving Patient #2 had been reported to the Department of Health, and the DQARM reported that it had. A letter dated February 5, 2013, from the Department's Complaint Intake Unit, stated that not enough information had been received to process the complaint, such as the patient's name and the date and time of the incident.

The letter also stated:
"The law allows you one opportunity to request reconsideration of the disciplinary authority's decision. To do so, you must provide new information about your original complaint within 30 days of receiving this letter. After 30 days, any new information will be treated as a new complaint..."

On 4/4/2013, the DQARM stated that s/he had not received the letter from the Department of Health within the 30 day window and had understood the letter to mean that s/he could not submit additional information. S/he confirmed that no additional information, including the patient's name and/or the name of the aide involved, had been submitted to the Department of Health. No further follow-up was made by the hospital to investigate the potential abuse/neglect of Patient #2.

The internal incident report regarding Patient #2 also noted that the aide had been accused of not changing the wet incontinent pads of patients and of not appropriately turning patients.

The hospital's policy "Abuse or Neglect of a Patient" was reviewed. The policy directives included the following:

"Policy
It is the policy of the Highline Medical Center to thoroughly investigate and report any allegation of patient abuse or any incident resulting in patient injuries which may be the result of abuse, neglect, an accident or be of an unknown source....

(2) Abuse:...Abuse may include, but is not limited to physical abuse, verbal abuse, sexual abuse...
d. Sexual Abuse: Inappropriate touching, sexual harassment, sexual coercion, or sexual assault.

C. Reporting
1. Should an employee of Highline Medical Center identify abuse, exploitation or neglect that has occurred within Highline:...

(b) The Director of Quality Services/Risk Management will determine appropriate steps, which may include contacting law enforcement or the Department of Social and Health Services and the Department of Health...
(d) If the individual holds a state certification or license, the appropriate state department will be notified by Human Resources if indicated..."

Multiple references were found throughout the policy that directed reporters to the Washington State Department of Social and Health Services (DSHS). Discussion was held with the Assistant Administrator and the DQARM about the requirement to report incidents occurring inside the hospital, and/or by personnel licensed or certified by the Department of Health, to the Department of Health, not DSHS.

On 4/4/2013, the DQARM stated that the inaccurate guidelines in the policy and procedure had not resulted in a report to the wrong agency, because no report had been made to either agency regarding either patient. The DQARM acknowledged that the facility's failure to report the incident involving Patient #1, and the ED technician who held 2 certifications from the State Department of Health, left the technician free to practice throughout the state without investigation and potential restriction of the credentials.

Reference deficiencies written under State Tag 0315